A recent review by Daniel Tomasulo describes Interactive Behavioural Therapy (IBT), a type of group therapy that has been shown to be beneficial for people with learning disabilities. The author describes IBT, discusses the current research into the effectiveness of IBT and makes suggestions for future research into IBT.
Mental health problems are more common in people with learning disabilities than in the general population. However, Tomasulo notes that there is little research conducted into people who have a dual-diagnosis of both a mental health problem and a learning disability.
Tomasulo argues that healthcare professionals are inadequately trained to help people with a dual-diagnosis and as a result it is common for mental health problems to be mis-diagnosed.
The reasons for this are complex. For example, people with a learning disability may find it more difficult to talk about abstract concepts such as their feelings and emotions. People with learning disabilities may also demonstrate symptoms that are not typical of mental health problems. As a result, people with a dual-diagnosis often to do not receive the support they need.
What is Interactive Behavioural Therapy?
IBT is a model of group psychotherapy that has been specifically designed for people with learning disabilities. There are a number of behaviours that make group therapy effective. These are known as ‘therapeutic factors’. The aim of IBT is to work through a four-stage model of therapy that encourages therapeutic factors to occur within the group.
A facilitator helps to guide the group through each stage, highlighting the therapeutic factors that take place. The four stages of IBT are:
- Orientation: The facilitator encourages members to begin to communicate with one another. The topic of conversation is not the main focus here. Instead the facilitator looks to identify any issues that occur as a result of a learning disability or associated health problem. This can include poor eye contact or difficulty hearing.
- Warming up and sharing: Members of the group are invited to speak about themselves. Rather than focus on the content of each person’s speech, facilitators closely observe the dynamic between members of the group. This stage allows group members to get ready to take part in the group.
- Enactment: This stage uses techniques from psychodrama in which each member of the group can role-play emotionally important situations. Methods used here include the ‘empty chair method’, ‘doubling’ and ‘role-reversal’.
- Affirming: The final stage allows facilitators to review the therapeutic factors that occurred during the session and provides a chance for group members to give feedback to one another.
What does research into Interactive Behavioural Therapy tell us?
Tomasulo’s review suggests that previous research has found IBT to be effective for people both with and without learning disabilities. It has also shown to be effective for people diagnosed with Schizophrenia and within specific situations such as when a person with a learning disability has experienced bereavement.
The review outlines a study conducted by Lundigan (2007) in which 40 people dual-diagnosis of both a learning disability and a mental health problem were interviewed about their experience of IBT. A high proportion of interviewees found IBT to be helpful (85%), reporting that they enjoyed the opportunity to give and receive help from the group.
There were also a number of wider personal and social benefits. Individuals reported that IBT had helped to improve their self-esteem (95%) and their relationships with other people (90%).
However, it is unclear from the review whether interviews were conducted immediately after IBT, or after a follow-up period. It is therefore not possible to determine how long the positive effects of the IBT are maintained.
Future research into Interactive Behavioural Therapy
Tomasulo looks towards to the field of Positive Psychology and its applicability to group therapy. Positive Psychologists believe that people with a negative, pessimistic thinking style can learn to be more optimistic. As a result, there has been lots of research into ways a person can have a more positive outlook and ultimately live a happier life.
Positive Psychotherapy (PPT) has been developed as a type of therapy that explores a person’s strengths and weaknesses.
Tomasulo’s review highlights a study conducted by Seligman and colleagues (2006) that found PPT to be successful in lowering symptoms of depression. Symptoms remained lowered even when the same people were re-assessed one year after the therapy took place.This is a particularly exciting and interesting finding.
Tomasulo raises the question of whether or not PPT is applicable to people with learning disabilities. Many parts of PPT require people to be able to read and write. Therefore future research will be needed to develop an adapted version for people with learning disabilities and members of the general population that do not have strong literacy skills.
However, Tomasulo promisingly points out that PPT already shows many similarities with the IBT model of group therapy.
For example ‘character strengths’ identified during PPT are similar to ‘therapeutic factors’ identified in IBT; such as the character strength of ‘hope’ and the therapeutic factor of ‘installation of hope.
The author also suggests a number of character strengths that are common within people with learning disabilities, such as bravery and persistence. Due to the similarity and compatibility of the two approaches, IBT has been modified to include 10minutes at the start of each session to consider each person’s strengths.
The author also discusses the concept of ‘gratitude’, used within Positive Psychology. Research has found that people who express gratitude have higher levels of self-esteem and improved relationships with other people.
During PPT, gratitude is expressed in therapy through an individually written letter. However, Tomasulo suggests that a simple way to make the concept of ‘gratitude’ applicable to people with learning disabilities would be to create a ‘virtual gratitude visit’.
A ‘virtual gratitude visit’ has been included as a role-playing exercise as part of an IBT session. Tomasulo describes how an individual can use the ‘empty chair’ method of role-playing to express gratitude to someone they know, used know, or even to a stranger that was kind. The individual can arrange two chairs in any way they find appropriate and expresses his or her gratitude for the person symbolised by the empty chair.
Strengths and Limitations
Within the world of research there is a tendency to only report studies that show a positive effect; therefore it is more likely that studies that have shown IBT to be effective will be available to read. This creates a risk that Tomasulo’s review of the evidence is somewhat biased. What is more, the author does not provide details on the strategy used to select relevant articles to be included in the review.
Therefore it is unclear whether factors such as the number of people in each study and the length of time between therapy and follow-up have been considered. However, the article provides a clear explanation of IBT, a summary of research into the effectiveness of IBT and highlights ways in which the IBT approach could be developed in the future.
Tomasulo, D.J. (2014), Positive group psychotherapy modified for adults with learning disabilities, Journal of Intellectual Disabilities, 18(4), 337 – 350 [abstract]
Seligman, M.E.P., Rashid, T., & Parks, A.C., (2006), Positive Psychotherapy, American Psychologist, 61, 774-788
Lundrigan, M. (2007), Interactive behavioural therapy with intellectually disabled persons with psychiatric disorders: a pragmatic case study, PsyD Thesis, Graduate School of Applied and Professional Psychology, Rutgers University, USA.